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Foremost among his findings: "The city of Key West should, as quickly as possible, take control of [emergency medical services], including emergency ambulance transportation."

Cohen says in a report he'll bring to the commission Tuesday that if the city decides to have the Fire Department provide ambulance service rather than continue to contract it out, the expected start-up cost would be around $650,000, which includes the purchase of ambulances. He says operations costs would be about $1.5 million annually.

Care/American Ambulance, formerly Lifestar, replaced American Medical Response in Key West in 2011 at no cost to the city. Care/American expected to make money by directly billing people it transports.

When American Medical Response had the city contract, the city paid it $650,000 a year, largely based on uncollectible ambulance rides for homeless people.

The Care/American contract expires Tuesday and the commission has already voted to pay the company $45,000 per month for up to a year until a transition can take place, either to the Fire Department or another for-profit company.

The Fire Department has a staff of 72 and an annual budget of $7.35 million. To bring 911 response in-house, Cohen projects the need for an additional 19 staff members (one EMS manager and 18 paramedic/firefighters) and an increase in the annual earmark to $8.925 million.

In 2012, the latest year for which numbers are available, Care/American responded to 5,388 calls. Using that figure, Cohen projected different collection rates against expected expenses.

With a 60 percent collection rate, the city would lose $364,169 each year in what he calls a "worst-case scenario." The "best-case scenario" is an 80 percent collection rate, which would earn the city $14,696.

That's called inter-facility transportation in the industry. Care/American managers have said they will continue that component of their business regardless of what happens with the emergency ambulance service.

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